PSYCHOACTIVE DRUG HISTORY QUESTIONNAIRE Program # _________ Client Name:__________________ Counsellor: ___________________ Date: ________________ DRUG TYPE Used in Past # of days How Long Typical Amount Clinical comments (e.g. drug name, 12 Months? used in Since Last on Each Day dosage, patterns, periods of abstinence, past 90 Drug Use? (see of Use in Yes No Refused Missing (1) NONE days codes below) the Last used only as prescribed, length of use, 1 2 8 9 90 Days* age of first use, etc.) (2) ALCOHOL: Beer/liquor/wine (3) COCAINE/CRACK: coke (4) AMPHETAMINES/OTHER STIMULANTS (5) CANNABIS: hash, weed, grass, pot, marijuana (6) BENZODIAZEPINES (7) BARBITURATES (8) HEROIN/OPIUM (9) PRESCRIPTION OPIOIDS How Long Since Last Used: 1=<24 hour 2=1-3 days 3=within last week 4=within last month 5=more than a month ago DRUG TYPE Used in Past # of days How Long Typical Amount Clinical comments (e.g. drug name, used in past Since Last on Each Day 12 Months? dosage, patterns, periods of abstinence, 90 days Drug Use? (see of Use in Yes No Refused Missing (1) NONE codes below) the Last used only as prescribed, length of use, 1 2 8 9 90 Days* age of first use, etc.) (10) OVER-THE-COUNTER CODEINE PREPARATIONS (11) HALLUCINOGENS (12) GLUE/OTHER INHALANTS (13) TOBACCO (14) OTHER PSYCHOACTIVE DRUGS How Long Since Last Used: 1=<24 hour 2=1-3 days 3=within last week 4=within last month 5=more than a month ago * See Guidelines for Describing “Amount” of Each Drug Use 90 DAY WINDOW: START DATE (dd/mm/yyyy) _______________ END DATE (Yesterday) (dd/mm/yyyy) ____________________ Addiction Research Foundation, 1997, a division of the Centre for Addiction and Mental Health. Used by permission..